DESCRIPTION (abstract): Acute stroke is the third leading cause of death and the leading cause of adult disability in the US. A disproportionate amount of morbidity and mortality falls on underserved populations. Reduction of health disparities has become a significant public health challenge and is a major goal of the Healthy People 2010 initiative. The programmatic goal of this proposal is to identify biological and socioeconomic factors contributing to ethnic disparities and to develop innovative approaches to reduce these disparities for ischemic and hemorrhagic stroke. Three research projects are proposed. Project 1, Acute Stroke Program of Interventions addressing Racial and Ethnic disparities (ASPIRE), is an intervention study designed to investigate whether implementation of a multilevel intervention can significantly increase the number of ischemic stroke patients appropriately treated with intravenous tissue plasminogen activator (IV tPA) in a predominantly underserved community. The primary outcome measure will be the percentage of all ischemic stroke patients appropriately treated with IV tPA. Project 2, Preventing Recurrence of Thromboembolic Events through Coordinated Treatment in the District of Columbia (PROTECT DC) is a randomized phase II clinical trial of the PROTECT DC intervention (hospital-based initiation of aggressive secondary prevention combined with navigator case management) vs. standard management in ischemic stroke patients from two underserved hospitals in the District of Columbia. The primary aims are 1) to refine the PROTECT DC design in preparation for a phase INI trial and, 2) to assess the effect of the intervention on 4 medication goals as defined by normalization of objective measures of secondary risk factor control. Project 3, DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) is a longitudinal, MR imaging, prospective, observational, cohort study designed to evaluate the prevalence and significance by race/ethnicity of chronic cerebral microbleeds in patients with primary intracerebral hemorrhage. Three cores will support the projects: A) Administration B) Participant Recruitment, Retention, Intervention and Outcomes, and C) Biostatistics / Data Management. This application is designed not only to define factors leading to racial/ethnic disparities in stroke treatment and outcomes, but also to demonstrate the efficacy of programs specifically designed to reduce these disparities. Project 1: Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities (ASPIRE) PI: Amie Hsia DESCRIPTION: Stroke, the third leading cause of death and the leading cause of adult disability in the United States, has a disproportionate impact on underserved populations that is reflected in higher incidence and mortality rates in these groups. Several studies have suggested that blacks are less likely than whites to receive intravenous tissue plasminogen activator (IV tPA), the only FDA-approved acute ischemic stroke therapy. Efforts are needed to elucidate factors contributing to racial/ethnic disparities in access to acute stroke care and to develop programs to overcome these barriers. The specific aims of this intervention project are: A) to identify previously unrecognized sociocultural and environmental barriers to acute stroke treatment in an underserved, urban population;B) to investigate whether implementation of a multilevel intervention designed to address these barriers can significantly increase the number of ischemic stroke patients appropriately treated with intravenous tissue plasminogen activator (IV tPA);and C) to perform program evaluation of the methods used in the intervention to determine which efforts are the most effective. The investigators will assist each of 6 hospitals in the District of Columbia to develop a team of Stroke Champions to implement educational programs and standardized procedures designed to improve acute stroke care. Five Baltimore hospitals will serve as the control group. Essential design features of this project include: 1) a focus on underserved populations to identify community-specific barriers and then tailor existing stroke education materials to increase health literacy and decrease delays in seeking treatment;2) implementation of interventions to address educational, attitudinal, and structural barriers at the public, paramedic and hospital levels;and 3) assignment of a dedicated research coordinator to each hospital who will also serve as a Stroke Champion. The long term objective of the trial is to identify systematic, reproducible, effective methods for improving the delivery of acute stroke therapies in underserved areas that can be implemented in a broader arena. The only way to definitively affect outcomes for underserved stroke patients is to elucidate the complex issues related to access to treatment, and the District of Columbia is the ideal city in which to perform these investigations.